BTK Episode 4 - clinical challenge CORS CCF
===

[00:00:00] Hi, everyone, and welcome to Behind the Knife. My name's Alyssa Dabaghi. I'm a general surgery resident at Cleveland Clinic.

And I'm Jared Hendren. I'm also a general surgery resident at Cleveland Clinic.

Hello there. I'm Joseph Trunzo. I'm one of the, uh, colorectal surgeons and, uh, general surgery program director at the Cleveland Clinic.

And I am AJ Kishenrao. Um, I'm one of the colorectal surgeons at, uh, Fairview, um, Hospital at Cleveland Clinic, and, um, yeah, happy to be here.

And my name's Dave Rosen. I'm the vice chair of the Department of Colorectal Surgery at Cleveland Clinic, and the section chief, uh, at Cleveland Clinic Fairview Hospital.

All right. So today we're tackling a problem any GI surgeon runs into eventually, the tough stoma. Sometimes you're challenged with an obese abdomen, a mesentery that just won't reach, or a colon so dilated you're not sure it'll even fit through the fascia. We're going to walk through a few cases and get your intraop decision-making, technical tips, and how you [00:01:00] troubleshoot when things aren't going according to plan.

So let's start with a case. Um, we have a 68-year-old woman with a BMI of 42. She presents overnight with acute abdominal pain, found to have free air and diffuse peritonitis, and the CT is concerning for a perforated diverticulitis. Um, she's tachycardic, mildly, mildly hypotensive, resuscitated, and taken to the OR emergently.

No preop stoma marking was done, and she came to the ED, um, straight from the ED to the OR. You end up performing a Hartmann's, and I was wondering, how do you guys approach siting a stoma preop in a patient such as this with a pannus-heavy abdomen?

Uh, you definitely wanna be very thoughtful about the location and where you put the stoma, like you mentioned, with a PANAS heavy patient.

So if the patient is stable in pre-op, I definitely would try to do a marking myself, um, as when the ostomy would not be available at this time of the night. Um, so, you know, have the patient kind of sit forward [00:02:00] kind of look for ... avoid f- uh, folds and creases, and try to pick a spot that is within the rectus muscle, um, that I would try to use in the upper abdomen, so that way I kind of avoid going through multiple layers of adipose tissue in the lower belly.

Yeah, I think I agree completely. You know, in these cases where you don't have the luxury of being able to have your, uh, an ostomy nurse if you are so lucky to have that at your institution mark before case, there, there usually is, even as you're going to huddle, in most cases, a, a minute to take to sort of at least ask the patient where do they wear their belt line, have them, if they can't sit up completely, at least kind of put the back of the bed up and see if you can figure out where some natural creases are in the abdomen.

Those are all sort of some strategies you can do to get a sense as to where would be good. In general, absolutely upper abdomen is better. The abdominal tends to be less thick there. And you can use your preoperative CT scan to try to help plan, uh, as well to see where the abdominal wall is thickest see where the diseased portion of colon is and what you think you'll be [00:03:00] bringing up and where a good spot for it may be.

All right. So what if, you know, you know, if all that doesn't happen and the patient's crashing or debilitated and you're really not able to mark them pre-op, are there any other, like, tips or tricks you have?

Yeah, I mean, I, I think that, um, some of the same principles still apply. I mean, you, you just-- I think you're-- you want to aim for the upper abdomen.

It's gonna be more readily available. It's gonna be easier to reach in that situation, and you're gonna be less likely to fall below the pannus into a difficult pouching situation. You're also, as Dr. Rosen mentioned, you're gonna have, if typically in an obese patient that has a larger pannus, you're gonna have a less adipose tissue to pass through above the rectus muscle, um, in the upper abdomen as opposed to the lower abdomen.

So, you know, technical speaking, you know, even if you can't oper- you know mark them preoperatively because of this, uh, sort of acute situation, you know, that the default would be a-- that would be a better approach looking [00:04:00] upward, uh, in the abdomen for that.

And you want to assess to make sure you're coming through the rectus abdominis itself.

You don't wanna go too close to the midli- your midline incision, presuming this is exploratory laparotomy, uh, and, and have issues with pouching over the midline. And you don't wanna go too lateral, uh, and, and devastate the linea semilunaris as well.

Right. Okay, so let's say you've fully mobilized the left colon, you're ready to bring up the end colostomy up through the abdominal wall, but even after full mobilization, it feels tight, and you're worried about tension.

Can y'all walk us through your t- troubleshooting? What do you check first? What technical moves buy you some extra length or a lower tension stoma in a patient similar to this?

Yeah, I mean, I think there's some basic things that you always wanna sort of fall back on in, in this situation. Um, you certainly wanna make sure that your your, your fascial opening is, is more generous.

This is not a time to worry about a peristomal hernia down the line. Make sure that you have an, an [00:05:00] adequate fascial opening. You can remove excess fat, epiploica from around the, the, um, ostomy to help with bringing it up to the abdominal wall. If you're, you're struggling with it, it's just not able to reach above the level of the skin well, you know, make sure that you have released it as far medially as possible from the retroperitoneum.

In some cases, you do have to mobilize the splenic flexure just to get that adequate reach, depending on how far up the disease goes, especially we're talking about sigmoid colon or left colon. And then, you know, the, the, it... Once you're sure that the mobilization is adequate, and you've sort of r- made all of those maneuvers around the, uh, releasing surrounding fat, then, you know, you can consider dividing the inferior mesenteric artery.

Um, it's not my go-to maneuver but, you know, if this was an oncologic case, we certainly do that, and that will give you lift from, uh, the retroperitoneum and off the aorta and, and give you some tension-free lift off the, uh, from posteriorly.

There is one more maneuver that I actually picked up from Dr.

Trunzo that's been [00:06:00] helpful when I've had some challenging cases, which is he puts a wound protector through the, uh, stoma trophin, and, um, that actually help compress the adipose tiss- the, uh, subcutaneous tissue so that you can kind of bring the ostomy up a little easier. The trick is obviously trying to get the, um, ostomy out afterwards.

Um, so you gotta be able to cut the inner portion of the, uh, wound protector and, um, you know, take that part off, and then you can slide the, slide the wound protector off. So I've used it a few times, and it's actually been a very handy trick in those very difficult end colostomy.

Dr. Trunzo is full of good tricks, Dr.

Kachinju, as we all, as we all know.

Yep.

Yeah, I think, I mean, you can actually, with... If you do use that maneuver with a, with a, um, a wound protector to bring the ostomy up through the abdominal wall, you can also use some surgical lubrication to, inside the, the lumen of the ostomy appliance. That helps.

And then, as she mentioned, you, you have to cut the ring from underneath the fascia and it's a little challenging. So you have to, you almost need, like, either wire cutters or, or s- uh, something heavy to cut through [00:07:00] that hard plastic from the internal ring so that you can slip it around the ostomy and slide the plastic from around the stoma once you've brought it up through the abdominal wall

All right.

So, any pearls for avoiding early stoma complications like necrosis, retraction, or a stoma that looks fine on the table but then declares itself unhappy on the floor, um, specifically in this sort of obese, non-elective patient population?

Yeah, I think the first thing that you wanna do while you're in the OR is just like any case, you wanna make sure your perfusion is adequate to your, to your stoma.

So if you need to do things like a high ligation of the IMA and full mobilization to help yourself get some adequate reach, you may wanna do some type of a perfusion test. For me personally, it's cutting the marginal artery sharply and seeing how the perfusion is, uh, before uh, tying it off. It, nothing makes you feel better about uh, your perfusion than seeing pulsatile flow.

Uh, you also have to be cognizant of what's going on with your [00:08:00] anesthesia colleagues. Are they on a whole bunch of pressures, pressors? What's the blood pressure? Those types of things to make sure you're not getting a false positive or false negative with that, uh, type of perfusion test. Some people like to use perfusion agents such as ICG for emergent open cases like this.

I personally am cutting the artery sharply. Um, so if you have good blood perfusion, uh, then that, that sort of is the, is the number one, uh, issue. Now, the other things to do are to make sure that, like was mentioned in the, in the previous conversation, that your, your opening is a- adequate of the fascia, that it con- it's not constricting, uh, there.

Uh, but in a patient who's sick and on pressors, the tip of the stoma may be, uh, dusky. Um, and so that can, that can often present itself, but you can use the old test tube test or kind of looking on the inside of the stoma in some, uh, aspect, some, some fashion to make sure that the mucosa is healthy down to the fascia.

As long as things are healthy, uh, below the fascia, then you can sit on that and you don't have to do [00:09:00] anything for that. In regards to retraction, the last thing you uh, mentioned you wanna make sure you have good um, maturation sutures of your stoma. I tend to do a small Bruch to try to get a little bit more, uh, pouch.

And for stomas that are really heavy, sometimes the inside I will do, uh, tacking sutures to the fascia to try to help keep it up and avoid any tension of the heavy stoma pulling down on the, uh, abdominal wall

And I would say just one thing I would add is I like to see when I pull it up that I can leave it there and it doesn't pull itself back down. That it actually just sits there without getting retracted down, not, not with me having to hold it up. So if I can pull it up and then it stay- sits above the surface of the skin without being pulled down spontaneously, that's always a little bit better.

Makes me feel a little bit better about, um, there's, that there's nothing gonna be pulling it downward or outward. And, you know, risk of stricture formation and retraction usually is a profusion issue and tension. Those are the probably your two biggest things.

Awesome. Yeah, this has been a great [00:10:00] discussion so far, guys.

Um, let's talk through another case. Um, let's say you have a 34-year-old woman with refractory UC who's failed medical management and is undergoing a total abdominal colectomy with an end ileostomy. Intraoperatively, her small bowel mesentery's thick and foreshortened, and the TI just won't reach the fascia without tension.

What's your approach here?

You're bringing up an end ileostomy and you're having trouble bringing it up sort of as a chimney as we more conventional conventionally would do. You, you can consider doing a, a, a loop end or an end loop, uh, ostomy. That will give you some extra length and d- and gives you with, especially with a mesentery that's sort of tethered down or retracted because of acute inflammatory response.

And, uh, you know, that it... And when you do that, just be mindful that when you're, that you're sort of delivering it up through the abdominal wall, not tugging up with a Babcock or an Allis, something that will tear the tissue, that it's, you're able to deliver it up. [00:11:00] I typically, if I do make an end loop ostomy, will use a rod like you would conventionally for a loop stoma.

And, uh, I only leave a rod in for maybe two days, um, before removing it just to help support the stoma as, in this particular situation. But a sort of end loop is a, is a, is a good maneuver in, in this particular, uh, indication.

Yeah. I think that, you know, those are all great strategies. Similar to the, the colonic case we're discussing, you can do your similar types of maneuvers that you would talk about and consider for extra reach for a pouch too.

You know, mobilize the attachments up to the SMA take, make sure everything is completely mobilized off the duodenum, even do some higher, uh, ligations or divisions of the mesentery while preserving the marginal blood supply, you know, taking a few of the arcades while preserving the marginal to get you some, uh, extra reach, scalloping the mesentery, all those types of things.

Just those will get you little bits of, of reach here and there.

Okay. [00:12:00] Now let's fast-forward a little bit and say she does well. She lost a significant amount of weight and returns for a completion proctectomy, ileal pouch-anal anastomosis, and you're going to do a diverting loop ileostomy. Now, um, you'd probably expect this to be easier given the weight loss, but let's just say her mesentery's still shortened and scarred down from her index case, and the loop just won't come up without tension.

How do you approach this the second time around, and at what point do you consider, you know, converting the loop to something else or maybe relocating the site altogether or something else?

For this situation I think some of the other maneuvers still applies. Um, but, you know, I would definitely make sure the bowel is well mobilized and there's no scar tissue adhesions, no intra-bowel loop adhesions that needs to be freed up.

And then I will go prox- a little more proximal if I need to, to find a bowel that has a a be- a better reach. 'Cause with [00:13:00] the small bowel, you, you do have to weigh the risk of having a more proximal stoma leading to a higher output. But I do think that is worth it in some of the situations, 'cause you can usually get the patients through fully with um, bowel sto- you know, the anti-motility agents.

So I would, you know, most likely go more proximal, try to use the umbilical, umbilical tape to gently kind of, uh, bring it through the stomach or phren, 'cause that can be very helpful when it's there's tension and it's for sure. And so those are kind of my go... My, that would be my go-to move in that situation.

In, in addition to make sure everything is well mobilized.

Yeah, I think you make a good point that when you're doing a, a pouch and the small bowel is now rather than being free and having a free edge of the mesentery that you bring up for an ostomy, the small bowel mesentery is now being drawn down into the pelvis where the, you know, ileal pouch anal anastomosis is.

And so the diverting loop ileostomy oftentimes has to be moved more proximal in that setting, uh, because the more distal ileal mesentery is really tethered down, [00:14:00] uh, by that pouch. Um, and so sometimes you do have to go more proximal than you'd, uh, wish to uh, get the stoma to reach.

Okay. Um, once you got, once you've got it up without tension any additional tips on the actual maturation in this case such as with technique or, um, avoiding retraction over the next few days?

I mean, I, I think the same principles apply. Once, once you have it up, and as I mentioned, as, as already been mentioned, uh, y- you may have to go a little more proximally. I typically would still use a stoma rod. People... It's a little controversial. Some people don't feel strongly about that in this situation.

But, um, I, I, I feel it does give a little, uh, level of s- sort of support to the stoma as it's sort of at least scarring itself in over the first couple of days post-operatively. Um, and, um, you know, you just have to be mindful if there's a lot of tension there. The reason why we don't leave rods in for extended period of times is you can cause pressure ulcerations [00:15:00] from the rod themself.

So I, I don't wanna leave those in for an extended period of time. I- it's sort of a short period in that ear- early post-op phase to give a little extra support to the loop coming up over the abdominal wall.

Yeah. I agree with Dr. Tronzo. I tend to, in those situation, also leave a stoma rod and, um, I just, I, y- I mean, maybe it's just for my comfort, maybe w- it'll be fine without it, but I...

if there's tension, I'm leaving a rod. I tend to take my rod out on day three. Um, most patients, everybody has different, um, you know, they, everybody has different practices, but I think day three is a good, uh, medium when in terms of taking it out. And then, uh, day five, if they're really malnourished and h- unhealthy and I'm worried about, you know, healing.

But anywhere between three to five days, I think is reasonable.

Okay. So for our last case, we have a 76-year-old male who presents with an obstructing rectal mass and a massively dilated thick-walled proximal colon with cecum measuring close to 12 [00:16:00] centimeters on CT and concerning for impending perforation.

He's a poor candidate for upfront resection given his comorbidities, so the plan is a diverting loop colostomy to decompress him and get him safely through any adjuvant therapy. Um, what's different about maturing a stoma in a colon this dilated and thickened compared to your standard elective loop colostomy?

Um, I know we've probably touched on a lot of this, but if you have any other pearls

Yeah, so this is one of those interesting ones. Um, I will say that, you know, when you have a dilated colon, both proximal and distal, and you would need to bring up both limbs to decompress, it does bring the, another challenge.

The size of the fascial opening is, tends to be quite a bit larger, and bringing up those two limbs is always quite difficult. Um, if you can do that, that is okay. You can proceed with dividing the two li- lumens up and bringing up the, the full end from the proximal limb and then the corner of the dis- defunctional limb up and just [00:17:00] opening that, like the corner of the closed staple off end, um, sort of as a mucus fistula in the same aperture, um, or trephine and so, the so-called Prasad loop, uh, divided loop colostomy.

And that, that is a, a way to kind of make it ma- manage it through that same trephine. You can also do two separate openings if you really need one distal and one proximal, if you cannot get both up to the same opening. But you will have to divide the mesentery in some degree if you're gonna separate those two lumens.

So those are probably the, you know, additional couple of maneuvers separate of what we've already discussed as far as mobilization. The one thing also, if you're using the transverse colon, it's really important to, um, mobilize the omentum off of the transverse colon so you're not having to bring that also up to the abdominal wall, and sometimes people forget about that.

Um, just re- free that off so you're basically skeletonizing all the excess fat off of the, the loops of colon that you need to manage.

Yeah. This is, uh, one of my dreaded cases, you know, type of cases when I'm on call. You s- [00:18:00] look at that CAT scan, you already know it's gonna be a long night, and it always happens in the middle of the night, right?

So, um, I definitely agree with Dr. Tran. So this situation is... I think my go-to is if I can, uh, do a, um, end colostomy with a mucus fistula, uh, because I think when the colon is this dilated, it can be very difficult. You can try to decompress the colon first. Um, I think that's a good way to try to, you know, take some of that tension off, because the tissue's gonna be very, um, di- you know, very thinned out, dilated, easy, uh, easy to tear.

So the last thing you wanna do is kind of, you know, as you're pulling it up, cause, you know, massive hole and then spills stool everywhere. So I think decompressing it first is, you know, if you wanted to do a loop. But otherwise, I'm very happy to do a end and not, you know, try to make my life more complicated in this situation if it's necessary.

And I think the fascial opening is very important in these cases as well.

Yeah, so with a obstructing rectal mass, I think there's a few additional things that I consider. One, the location [00:19:00] of your stoma. Um, and so if possible, if, if... Ultimately, this gentleman likely will be going for a rectal resection, and so if you can get, if you can find a way to make this a sigmoid colostomy, my partners have, have made great points about, uh, Prasad divided loop versus, uh, uh, end with a mucus fistula as ideas.

But if there, if you, if it's not so tethered down by the rectal mass, you can do a sigmoid colostomy. I think that's the, the preferred location because that'll be coming out anyway with the ultimate resection, versus if it's a transverse loop, then you have to decide, well, what are you gonna do at that point?

Do you take that down, or do you bring it all the way, do your resection all the way up to that transverse loop? So as distal as possible, I guess, is the message on the colostomy there for a rectal, obstructing rectal mass. Two, which might also change and affect your decision is, what's the, what's the quality of the rest of the colon?

Oftentimes, the cecum will start having this striatal splitting and be about to perforate, and you feel like you have to remove it anyway. In that case, you might be doing an ileocolic resection with a ascending colon colostomy as [00:20:00] a, uh, excuse me, ascending colon mucus fistula and an end ileostomy. So that's another option.

Uh, and t- and the last thing I'd say, and the strategy that I often use is, if the oftentimes in these cases, the colon is so thick and edematous from this chronic buildup of this obstruction that it's really hard to manipulate. It's so, it's like th- as, as firm as a drum. And oftentimes, you can get the sense of this from the CT scan, a lot of times it's filled with gas versus stool.

It's harder to deal with if it's stool, but if it's gas, and, and usually a good component of it is, usually I'll, I'll select where I think I'm gonna be doing my colostomy, kind of as distal as, as possible as I think will reach after my assessment of, uh, any mobilization or just kinda seeing the, the redundancy of the colon.

And I'll put in a a, a, a purse string, like a 2-0 Vicryl stitch, uh, around the corner, and I'll, then I'll, uh, make a hole right in the middle of it, uh, to decompress the gas. Uh, just pop in with a, uh, either, like, a tonsil or, or Bovie into it, and [00:21:00] that'll release a lot of the gas. And then you have that purse string that you can just tie down and then use that as a handle to bring up, uh, through your aperture.

Uh, and that's a good technique I found, uh, to help me with these massively dilated, thickened colons.

That's great. Those are really great tips. What about, like, long-term risks such as prolapse, given how dilated and redundant that colon is, or anything else that changes kind of post-op management and surveillance and such?

Well, I think that whenever you're dealing with a chronically dilated colon and you have to bring it up as an ostomy, whether it's a loop or an end, a loop's probably gonna be more likely to prolapse once the edema and the dilation does dissipate over time, and that, that's something that i- is, is just inevitable and it's really not...

there's not a lot you can do to avoid in that situation. I think you, you may see a little less of that if you had, you sort of have some kind of divided end than you versus a loop. But, uh, you know, you just have to acknowledge that, that, that [00:22:00] may be, that may occur. And there are times where you have to revise the stoma down the line if it's not, if it's not time to definitively manage the rectal cancer and just revise the stoma to get them through.

Uh, or they manage just living with the prolapse until you're ready to do the definitive ca- oncologic procedure. So it, it just sort of depends on a case to case-by-case basis.

Yeah, I agree. In this case, you know, this is an emergent situation, so you're just trying to get out of dodge and get the patient safely through this operation.

So most of the times I'm doing a loop colostomy just in this setting is, is usually an easier thing to do with this massively dilated colon, accepting the fact that likely there'll be some type of stoma issue here, uh, whether it's a prolapse or just difficulty with pouching and leaking, 'cause not an ideal stoma.

And, and this patient's gonna go on. You're, you're just trying to get him through this, get him through his neoadjuvant treatment. Ultimately, he'll have surgery where you can fix the stoma. If I'm doing an elective case and uh, say I'm doing an end colostomy of some sort, I do try to, uh, not have any ex- [00:23:00] excessive redundancy of the colon intra-abdominally after pulling it through, and sometimes that requires pulling more out and then amputating so it's, it's, it's not, you know, so it's not...

or so it's, uh, uh, the mesenteric edge is, is straight and not floppy and redundant, so that way you don't have excess redundancy that's gonna set them up for prolapse. But that I consider more an elective setting than a, than a case like this.

All right. And before we close this out, I know we're getting close to being done on time.

Um, if you guys had to boil this down to, say, just a handful of principles that can apply no matter which, um, you know, challenging stoma you're dealing with, what would they be?

I would say very first thing is thinking about the location. Uh, as we talked about and started off with, you wanna pick a location, uh, that is, you know, gonna be usable for the patient accessible for the patient, um, but also for you as well, uh, bringing the stoma through the trophin.

You wanna be able to, um, avoid, uh, difficult locations. [00:24:00] You wanna think about the type of stoma you making. So, you know, sometimes I would, I would even make a ileocolic anastomosis so I can make an end colostomy as opposed to end ileostomy. So I think, think about the type of stoma you making. Do you have to make a...

Can you make a loop? Do you have to make a loop? Can you make an end? So I think those can make a difference. And then as we talked about, those little maneuvers makes a, makes a huge difference. Make sure your stoma is tension-free and has good perfusion to hopefully, uh, minimize complications down the line.

Um, I think that's kind of the things I think about when I'm making a stoma.

I divide it down into preoperative and intraoperative considerations. Preoperative, take the five minutes, even in an emergent case, to look through the CT scan and have a plan. Preoperative mark when you can, think about where your stoma is likely to be, what issues you might run into, and then intraoperatively, make sure you're assessing perfusion, make sure you're assessing tension, and then have the ability and capability to deviate from your preoperative plan based on the [00:25:00] intraoperative factors you find that cause you to do something different than what you thought you would be doing.

Well, everyone, I, I wanna apprecia- thank you all for listening today to our episode. We, uh, appreciate you joining us and, uh, as always follow us anytime in the next episode of Behind the Knife and dominate the day.